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SAN JOAQUIN COUNTY • Page 1 <br /> ENVIRONMENTAL HEALTH DEPARTI <br /> 1868 E HAZELTON AVENUE <br /> STOCK'ON', CA 95205 <br /> Phone: (209) 468-3420 <br /> INVOICE AccounuD AR0039202 <br /> Facility ID FA0001909 <br /> LMMMONNNMNWMMMN <br /> Date Printed 1/29/2015 <br /> ELDER, FASSEL M & ANN RE : COUNTRY CLUB FOOD & FUEL MINI MART* <br /> COUNTRY CLUB FOOD & FUEL MINI MART* 1856 W COUNTRY CLUB BLVD <br /> 4880 PEACH AVE STOCKTON, CA 95204 <br /> MANTECA, CA 95336 <br /> OWNER : ELDER, FASSEL M &ANN <br /> Dale Health <br /> Pfoyrarn, Desaipticr. Ani <br /> Invoice# IN0263314---Date of Invoice: 1129/2015 ll l l 111 V IVI II II ull ull l l ll VI V I V I I I I 1111111111111 <br /> 1/29/2015 1920 HMBP-Common Materials $ 100.00 <br /> 1/29/2015 2220 SM HW GEN <5 TONS/YR $ 213.00 <br /> 1/29/2015 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/29/2015 2301 UST STATE SURCHARGE FEE $ 15.00 <br /> 1/29/2015 2360 ADDITIONAL UST $ 130.00 <br /> 1/29/2015 2362 UST FACILITY&1 TANK $ 550.00 <br /> 1/29/2015 2399 UNIFIED PROGRAM FAC STATE SURCHARGE FEE $ 35.00 <br /> Total for this Invoice $ 1,058.00 <br /> Payment Due Date 2/28/2015 <br /> TOTAL DUE this Billing Period $ 1,058.00 <br /> Please make Checks PAYABLE to: 'EHD' — Return a Copy of This STATEMENT with Your PAYMENT <br /> Penalties will be added to all Permit Fees For HMBP Fees For all SERVICE FEES <br /> at the Rate of 100%of the Base Fee Penalties will be added at the Rate of 10% Penalties will be added at the Rate of 10% <br /> 30 Days after the Due Date 45 Days after the Invoice Date 60 Days after the Invoice Date and each 30 Days thereafter <br /> 5254 rpt <br />